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  • Question 1 - A 45-year-old writer presents to his routine follow up at the Nephrology Clinic...

    Incorrect

    • A 45-year-old writer presents to his routine follow up at the Nephrology Clinic complaining of numbness and tingling sensation of his right fingers. This worsens when he types for more than an hour and slightly improves when he stops typing. He suffers from diabetes mellitus and end-stage kidney disease and has been on regular haemodialysis via brachiocephalic fistula on his right antecubital fossa. On examination, his right radial artery is palpable and he has reduced sensation in all his right fingers, predominantly affecting the fingertips. The numbness does not worsen with tapping over the wrist nor with forced flexion of his wrists. His capillary refill time over his right fingers is prolonged to three seconds.
      Which of the following is the most likely diagnosis?

      Your Answer: Diabetic neuropathy

      Correct Answer: Fistula steal syndrome

      Explanation:

      Differential Diagnosis for Numbness in a Patient with Arteriovenous Fistula

      Fistula Steal Syndrome, Carpal Tunnel Syndrome, and Diabetic Neuropathy are Possible Causes of Numbness in a Patient with Arteriovenous Fistula

      Arteriovenous fistula is a common procedure for patients undergoing hemodialysis. However, up to 20% of patients may develop complications such as fistula steal syndrome, which occurs when the segment of artery distal to the fistula is narrowed, leading to reduced arterial blood flow to the limb extremities. This can cause numbness and worsening of symptoms on usage of the hands.

      Other possible causes of numbness in this patient include carpal tunnel syndrome, which is a common complication among patients on long-term renal replacement therapy due to protein deposition in the carpal tunnel, and diabetic neuropathy, which is a common complication of chronic diabetes mellitus. However, the loss of sensation in peripheral neuropathy in diabetic patients is symmetrical in nature, commonly following a glove and stocking pattern.

      Radial nerve palsy and ulnar styloid fracture are less likely causes of numbness in this patient, as they typically present with muscle weakness and a history of trauma, respectively. A thorough differential diagnosis is necessary to determine the underlying cause of numbness in patients with arteriovenous fistula.

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      • Renal
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  • Question 2 - A 60-year-old woman presents for review of her chronic kidney disease.
    Her investigation results...

    Incorrect

    • A 60-year-old woman presents for review of her chronic kidney disease.
      Her investigation results show:
      Investigation Result Normal range
      Calcium 1.70 mmol/l 2.20–2.60 mmol/l
      Potassium 6 mmol/l 3.5–5.0 mmol/l
      Phosphate 2.5 mmol/l 0.70–1.40 mmol/l
      Urea 80 mmol/l 2.5–6.5 mmol/l
      Creatinine 400 μmol/l 50–120 μmol/l
      What is the mechanism for the low calcium?

      Your Answer: Reduced vitamin D binding of calcium

      Correct Answer: Reduced vitamin D hydroxylation

      Explanation:

      This patient has hypocalcaemia due to chronic renal failure, which reduces the production of calcitriol, the active form of vitamin D that plays a crucial role in calcium absorption. Calcitriol increases the permeability of tight junctions in the small intestine, allowing for the absorption of calcium through both passive and active pathways. In the active pathway, calcitriol stimulates the production of calbindin, which helps transport calcium into the enteral cells. However, in chronic kidney disease, the hydroxylation of calcidiol to calcitriol is impaired, leading to reduced calcium absorption and hypocalcaemia. Other potential causes of hypocalcaemia, such as increased tubular loss of calcium or a parathyroid tumour, have been ruled out in this patient.

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      • Renal
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  • Question 3 - A 59-year-old man has been undergoing regular haemodialysis for the past 6 years....

    Correct

    • A 59-year-old man has been undergoing regular haemodialysis for the past 6 years. He previously had an AV fistula in his left arm, but it became infected 4 years ago and was no longer functional. Currently, he is receiving dialysis through an AV fistula in his right forearm. He presents with pain in his right hand and wrist. Upon examination, there is redness and a necrotic ulcer on his right middle finger. His right hand strength is normal. He is not experiencing any constitutional symptoms and is not taking any medications. He had undergone uncomplicated dialysis the day before. What is the likely diagnosis?

      Your Answer: Distal hypoperfusion ischaemic syndrome (DHIS)

      Explanation:

      Possible Complications of AV Fistula in Dialysis Patients

      AV fistula is a common vascular access for patients undergoing dialysis. However, it can lead to various complications, including distal hypoperfusion ischaemic syndrome (DHIS). DHIS, also known as steal syndrome, occurs when blood flow is shunted through the fistula, causing distal ischaemia, which can result in ulcers and necrosis. Surgical revision or banding of the fistula may be necessary in severe cases. Older patients with atherosclerotic arteries are more prone to DHIS. Other possible complications include unrelated local pathology, infected AV fistula, infective endocarditis, and thrombosis with distal embolisation. It is important to identify and manage these complications promptly to prevent further harm to the patient.

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      • Renal
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  • Question 4 - A 16-year-old adolescent presents to the clinic with gross haematuria. He is currently...

    Incorrect

    • A 16-year-old adolescent presents to the clinic with gross haematuria. He is currently suffering from a sinus infection. Apparently he had a previous episode of haematuria some 2 years earlier which was put down by the general practitioner to a urinary tract infection. Examination of notes from a previous Casualty attendance after a football game revealed microscopic haematuria on urine testing. On examination, his blood pressure is 130/70 mmHg. Physical examination is unremarkable.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 133 g/l 135–175 g/l
      White cell count (WCC) 8.2 × 109/l 4–11 × 109/l
      Platelets 240 × 109/l 150–400 × 109/l
      Sodium (Na+) 141 mmol/l 135–145 mmol/l
      Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
      Creatinine 110 μmol/l 50–120 µmol/l
      Urine Blood ++, protein +
      C3 Normal
      Serum IgA Slight increase
      Which of the following is the most likely diagnosis?

      Your Answer: Post-streptococcal glomerulonephritis

      Correct Answer: IgA nephropathy

      Explanation:

      Differential Diagnosis for Haematuria: A Case Study

      Haematuria, or blood in the urine, can be a concerning symptom for patients. In this case study, a patient presents with haematuria and a recent history of respiratory tract infection. The following differential diagnoses are considered:

      1. IgA nephropathy: This is the most common primary glomerulonephritis in adults and is often associated with a recent respiratory tract infection. Despite haematuria, renal function is usually preserved.

      2. Post-streptococcal glomerulonephritis: This diagnosis typically presents 2-4 weeks after a respiratory or skin infection. As the patient is still experiencing respiratory symptoms, this diagnosis is less likely.

      3. Lupus nephritis: This is a serious diagnosis that presents with haematuria, oedema, joint pain, and high blood pressure. As the patient does not exhibit these additional symptoms, this diagnosis is unlikely.

      4. Henoch-Schönlein purpura: This diagnosis is characterized by a rash, which the patient does not exhibit, making it less likely.

      5. Alport syndrome: This is a genetic condition that presents with kidney disease, hearing loss, and eye abnormalities.

      In conclusion, the patient’s recent respiratory tract infection and preserved renal function suggest IgA nephropathy as the most likely diagnosis. However, further testing and evaluation may be necessary to confirm the diagnosis.

    • This question is part of the following fields:

      • Renal
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  • Question 5 - A 50-year-old man with long-standing insulin-dependent diabetes mellitus was on dialysis, secondary to...

    Correct

    • A 50-year-old man with long-standing insulin-dependent diabetes mellitus was on dialysis, secondary to end-stage renal disease (ESRD). Three months ago, he received a kidney transplant, with his old kidney left in place. The transplanted kidney is attached to the central circulation, mimicking natural circulation. There are absolutely no signs of rejection, and the kidney is working perfectly. The patient is surprised to find out that he no longer has ‘thin blood’ because it has been years since he has not required medical management for his anaemia.
      What is the main factor responsible for the normalization of his blood parameters and his recovery, following the kidney transplant?

      Your Answer: Erythropoietin (EPO)

      Explanation:

      The Role of Kidney Function in Anaemia of ESRD Patients

      Erythropoietin (EPO) is synthesized and secreted by the kidney, making it a crucial factor in maintaining haematopoiesis. Patients with end-stage renal disease (ESRD) often suffer from severe anaemia and require exogenous EPO to address this issue. A hypoproliferative disorder, ESRD may or may not be accompanied by anaemia of chronic disease or iron deficiency, leading to decreased reticulocytes. Iron supplementation is often necessary in conjunction with EPO to maintain haematopoiesis in dialysis patients.

      Renin, on the other hand, is not implicated in anaemia. Aldosterone, which is part of the renin-angiotensin pathway that originates in the kidney, is not directly involved in anaemia either. Any derangement in aldosterone levels secondary to ESRD would have been normalized by now in the kidney.

      Normalizing kidney function may improve the iron levels of the patient, but the primary effect of renal disease is insufficient EPO secretion, leading to anaemia. Patients with ESRD are typically phosphate-overloaded and calcium-deficient. While a transplant may lead to decreased phosphate levels due to increased clearance, this is not directly implicated in haematopoiesis.

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      • Renal
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  • Question 6 - A 7-year-old girl presents with haematuria, hearing loss, and poor eyesight caused by...

    Correct

    • A 7-year-old girl presents with haematuria, hearing loss, and poor eyesight caused by lens dislocation. After conducting additional tests, the diagnosis of Alport syndrome is made. What type of collagen is typically affected by a molecular defect in this disease?

      Your Answer: Type IV

      Explanation:

      Types and Effects of Collagen Defects on Human Health

      Collagen is an essential protein that provides structural support to various tissues in the human body. Defects in different types of collagen can lead to various health conditions. Type IV collagen is crucial for the integrity of the basement membrane, and mutations in its genes can cause Alport syndrome, resulting in haematuria, hearing loss, and visual disturbances. Type III collagen defects cause Ehlers–Danlos syndrome, characterized by joint hypermobility, severe bruising, and blood vessel defects. Type I collagen defects lead to osteogenesis imperfecta, characterized by brittle bones, abnormal teeth, and weak tendons. Kniest dysplasia is caused by defects in type II collagen, leading to short stature, poor joint mobility, and eventual blindness. Kindler syndrome is characterized by the absence of epidermal anchoring fibrils due to defects in type VII collagen, resulting in skin fragility. Understanding the effects of collagen defects on human health is crucial for diagnosis and treatment of these conditions.

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      • Renal
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  • Question 7 - A 58-year-old man is admitted with severe shortness of breath during the early...

    Correct

    • A 58-year-old man is admitted with severe shortness of breath during the early hours of the morning. Past history of note includes difficult-to-manage hypertension, for which he now takes amlodipine 10 mg, indapamide 1.5 mg and doxazosin 8 mg. He failed a trial of ramipril 1 year earlier due to a rise in his creatinine of 40% at the 1-week post-initiation stage. On examination, he has a blood pressure of 185/100 mmHg and a pulse of 100 bpm regular and is in frank pulmonary oedema. When you review his old notes, you find this is the second episode during the past 6 months. Echocardiography has shown a preserved ejection fraction. An electrocardiogram (ECG) reveals no abnormalities.
      Which of the following is the most likely diagnosis in this case?

      Your Answer: Renal artery stenosis

      Explanation:

      Differential diagnosis of hypertension with rising creatinine and pulmonary oedema

      When a patient presents with difficult-to-control hypertension and rising creatinine, accompanied by episodes of pulmonary oedema without signs of myocardial infarction, the differential diagnosis should include renovascular disease. Abdominal ultrasound may reveal kidneys of different sizes due to poor arterial supply to one side, but angiography or magnetic resonance angiograms are needed for confirmation. Vascular intervention, mainly via angioplasty, may improve the condition, but patients may have other arterial stenoses and be at risk of other vascular events.

      Renal vein thrombosis is another possible cause of rising creatinine, especially in nephrotic syndrome, but it tends to have an insidious onset. Phaeochromocytoma, a rare tumor that secretes catecholamines, can present with hypertension, palpitations, and flushing, but it is unlikely to cause a rise in creatinine after starting an ACE inhibitor. Myocardial infarction is ruled out by a normal ECG and preserved left ventricular ejection fraction. Nephritic syndrome, which is associated with hypertension and oedema, is also unlikely to cause a rise in creatinine after an ACE inhibitor trial.

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      • Renal
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  • Question 8 - A 42-year-old accountant presents to the General Practitioner (GP) with flank pain and...

    Incorrect

    • A 42-year-old accountant presents to the General Practitioner (GP) with flank pain and an episode of frank haematuria. She has a history of recurrent urinary tract infections (UTIs) and has had similar symptoms before. She attributes this episode to another UTI. She also has hypertension which is well controlled with ramipril. The doctor is concerned regarding the history of recurrent UTIs, and patient is further investigated for her symptoms with blood tests and ultrasound imaging. Results of the bloods and ultrasound confirms a diagnosis of polycystic kidney disease (PKD). Which of the following is true regarding PKD?

      Your Answer: Is caused by a mutation in polycystin-1 in all cases

      Correct Answer: Is associated with berry aneurysms of the circle of Willis

      Explanation:

      Polycystic Kidney Disease: Causes, Symptoms, and Associations

      Polycystic kidney disease (PKD) is a genetic disorder that affects the kidneys and other organs. It is caused by mutations in either the PKD1 or PKD2 gene, which leads to the formation of multiple cysts in the kidneys. Here are some important facts about PKD:

      Associations with other conditions: PKD is associated with cerebral berry aneurysms, liver cysts, hepatic fibrosis, diverticular disease, pancreatic cysts, and mitral valve prolapse or aortic incompetence.

      Inheritance: PKD is usually inherited as an autosomal dominant condition, meaning that a person only needs to inherit one copy of the mutated gene from one parent to develop the disease. Autosomal recessive PKD is rare and has a poor prognosis.

      Kidney involvement: Both kidneys are affected by PKD, with cysts replacing the functioning renal parenchyma and leading to renal failure.

      Age of onset: PKD usually presents in adult life, but cysts start to develop during the teenage years. The mean age of ESRD is 57 years in PKD1 cases and 69 years in PKD2 cases.

      PKD is a complex disorder that can have serious consequences for affected individuals. Early diagnosis and management are crucial for improving outcomes.

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      • Renal
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  • Question 9 - A 35-year-old teacher is tested for compatibility to donate a kidney to his...

    Correct

    • A 35-year-old teacher is tested for compatibility to donate a kidney to his older brother, who has end-stage renal failure. To his joy, he is found to be a suitable match. The patient is then thoroughly counselled regarding the operative procedure, short- and long-term risks, and the implications of living with one healthy kidney. He is particularly interested to learn how his body will adapt to having only one kidney.
      What will be decreased in the donor after the kidney transplant?

      Your Answer: Creatinine clearance

      Explanation:

      Effects of Kidney Donation on Renal Function and Electrolytes

      Kidney donation involves the removal of one healthy kidney, which can have various effects on the donor’s renal function and electrolyte levels. One notable change is a decrease in creatinine clearance due to the reduced number of glomeruli. However, creatinine production remains unaffected by the surgery and depends on factors such as muscle mass, diet, and activity.

      Serum sodium levels should remain stable as long as the remaining kidney functions properly. Similarly, serum potassium levels should not change if the remaining kidney is healthy. However, plasma creatinine concentration may initially increase after kidney donation due to hyperfiltration, but it will eventually plateau and decrease over time.

      Overall, kidney donation can have significant effects on the donor’s renal function and electrolyte levels, but with proper monitoring and care, most donors can lead healthy and normal lives with one kidney.

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      • Renal
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  • Question 10 - A 49-year-old man, with known polycystic kidney disease (PKD), presents with acute-onset fever,...

    Incorrect

    • A 49-year-old man, with known polycystic kidney disease (PKD), presents with acute-onset fever, left mid-back pain and occasional chills. He has no dysuria or haematuria. The left renal angle is tender. The white cell count is 27.8 × 109/l, with 92% of neutrophils (54–62%). What is the most appropriate diagnostic tool to confirm the suspected diagnosis?

      Your Answer: Ultrasonography of the kidneys

      Correct Answer: Blood culture

      Explanation:

      Diagnosing and Treating Infection in Kidney Cysts: Medical Tests and Procedures

      Infection in kidney cysts is a common complication in patients with polycystic kidney disease (PKD). However, diagnosing and treating this condition can be challenging. Here are some medical tests and procedures that are commonly used to diagnose and treat infection in kidney cysts.

      Blood Culture
      Blood cultures are more reliable than urine cultures in detecting infection in kidney cysts. Gram-negative bacteria are the most common cause of infection in these cases. Antibiotics such as fluoroquinolones, co-trimoxazole, or chloramphenicol are often used to treat the infection. Treatment may last for 4-6 weeks, and surgical drainage may be necessary in some cases.

      Computed Tomography (CT) Scan of the Abdomen
      CT scans can detect internal echoes in one or more cysts, but they cannot differentiate between infection and hemorrhage. Therefore, CT scans alone cannot confirm an infection.

      Urine Culture
      Urine cultures may be unreliable in detecting infection in kidney cysts because cysts often have no communication with the collecting system.

      Ultrasonography of the Kidneys
      Ultrasonography can detect internal echoes within a cyst, but it cannot differentiate between infection and hemorrhage.

      Scintiscan of the Kidneys
      Scintiscans are not used to diagnose infected cysts.

      In conclusion, diagnosing and treating infection in kidney cysts can be challenging. Blood cultures are the most reliable test for detecting infection, and antibiotics such as fluoroquinolones, co-trimoxazole, or chloramphenicol are often used to treat the infection. CT scans and ultrasonography can detect internal echoes in cysts, but they cannot differentiate between infection and hemorrhage.

    • This question is part of the following fields:

      • Renal
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